Transulnar approach and chronic radial artery occlusion - Sasko Kedev

1. Transulnar access and
chronic radial artery
occlusion
Sasko Kedev

2. Financial disclosures
• None

3. Why Wrist
Artery Access ?

4. Femoral environment

5. Radial access

6. Radial access site complications
 Radial artery occlusion
 Midforearm hematoma
 Radial artery Pseudoaneurysm
 Bleeding with resultant Compartment Syndrome

7. RA pitfalls and technical considerations
Lo T.S. et al. Heart 2009; 95: 410–415.
Technical failure for RA procedures is between 1–10%
 Access
 Radial artery spasm
 Anatomical variations
 Curves & Loops: radial, brachial
Baumann F. et al. J Interv Cardiol 2015;28:574–582.
.

8. Vascular access and stent type Classᵃ Levelᵇ
Radial over femoral access is recommended for
coronary angiography and PCI..
I A
The use of new-generation DES over BMS should be
considered among patients requiring OAC.
IIa B
Roffi M et al. EHJ, 37, 267–315, (2016)
2015 ESC Guidelines for NSTEACS

9. Recommendations for procedural aspects of the primary PCI strategy
Primary PCI of the IRA is indicated. I A
Stenting is recommended (over balloon angioplasty) for primary PCI. I A
Stenting with new-generation DES is recommended over BMS for primary
PCI.
I A
Radial access is recommended over femoral access if performed by an
experienced radial operator.
I A
Routine use of thrombus aspiration is not recommended. III A
Routine use of deferred stenting is not recommended. III B
Ibanez B et al. EHJ, (2017) 00, 1–66 doi:10.1093/eurheartj/ehx393
2017 ESC guidelines for STEMI

10.  Alternative of RA
 Larger diameter and
straighter course
 More deeply seated
 Near ulnar nerve
Ulnar Access

12. Superficial and deep palmaric arch

13. Ulnar artery puncture

14. Ultrasound guided puncture
Courtesy of Dr. Zoltán Ruzsa

15. Ulnar access

18. RUA with sheathless 7.5F GC

19. Ulnar artery access

20. Ulnar artery high take-off

21. Ulnar artery high take-off

22. UA high take–off from the axillary artery

23. UA after failed RA

24. UA after failed RA

25. Radial artery loop

26. Failed RA followed by IUA

27. Ulnar artery access

28. Ulnar access with ipsilateral RAO

29. J Am Coll Cardiol. 2014;63(18):1842-1844.
Courtesy of Ian C. Gilchrist
Large vascularization of the hand

30. Ulnar artery access when RA is not
available
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.

31. (n=476)
Procedural success 462 (97%)
Crossover to TFA 14 (3%)
Heavily calcified UA 9 (64.2%)
Small UA size 3 (21.5%)
Severe clinical UAS 2 (14.3%)
Clinical ulnar artery spasm 40 (8.4%)
Grade I 34 (7.1%)
Grade II 4 (0.08%)
Grade III 2 (0.04%)
Grade IV 0
Study endpoints
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.

32. IRAO group
(n=240)
Non-IRAO group
(n=236)
P
value
Procedural success 232 (97%) 230 (97%) NS
Clinical ulnar artery spasm 17 (7.0%) 17 (7.2%) NS
Outcomes of patients based on ipsilateral
radial artery status
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.

33. IRAO group
(n=240)
Non-IRAO
group
(n=236)
P
value
Hemathoma Grade I-V 19 (7.9%) 20 (8.4%) NS
Grade 1 9 (3.7%) 9 (3.8%) NS
Grade 2 5 (2.0%) 5 (2.1%) NS
Grade 3 4 (1.6%) 5 (2.1%) NS
Grade 4 1 (0.4%) 1 (0.4%) NS
Grade 5 0 0 NS
Major vascular complications at 30 days 0 0 NS
Ulnar artery occlusion at 30 days 0 15 (6.3%) <0.01
Vascular access site complications
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.
Outcomes of patients based on ipsilateral
radial artery status

34. Artery access for STEMI PCI 2007-2014
5.70%
5.80% 4.40%
1.60%
0.10% 0.10% 0.00% 0.00%
25.50% 35.10%
59.60%
95.30%
98.50%
99.70% 99.90% 99.96%
74.50%
64.90%
40.40%
4.70%
1.50% 0.30% 0.10%
0.04%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2007 2008 2009 2010 2011 2012 2013 2014
crossover to TFA TRA TFA
Kedev S. et al, Catheter Cardiovasc Interv 2014;83:E51–60.

35. TUA 2011-2017

36. Total wrist access in 99% of all patients
Clinical Variables
March 2011-June 2017
Total N of Patients
N=34 071
TRA 31917 (93.6%)
LRA 515 (1,5%)
TUA 1482 (4,3%)
TFA 101 (0,29%)
TBA 53 (0,1%)

37. Total wrist access in 99% of all patients
93.69%
1.5%
4.4%
0.3%
0.2%
Total N Pts 34071
RRA
LRA
TUA
TFA
TBA

38. TUA from 2011-2017

39. TUA RAO vs. NRAO

40. TUA access site complications
N
Access site bleeding
complications EASY score
85 (5,7%)
Hematoma grade 1 57 (3,8%)
Hematoma grade 2 16 (1%)
Hematoma grade 3 11 (0,7%)
Hematoma grade 4 1(0,06%)
Hematoma grade 5 0 (0%)
Major vascular complication 0 (0%)
Signs of hand ischemia 0 (0%)
N
Clinical RA spasm
Grade I
Grade II
Grade III
Grade IV
52 (3,4%)
50(3,3%)
2(0.13%)
0 (0%)
0 (0%)

41. Dahal et al. CCI 87:857-865 (2016)
TUA vs TRA for Coronary Angiography or PCI
A meta-analysis of randomized controlled trials
MACE, composite of access-related complications, and cross-over rates

42. TUA vs TRA for coronary angiography or PCI
A meta-analysis of randomized controlled trials
Dahal et al. CCI 87:857-865 (2016)
Puncture rates

43. Rajendra Gokhroo et al. J Invasive Cardiol. 2016;28(1):1-8.
Ulnar artery interventions
non-inferior to radial approach (AJULAR)

44. Rajendra Gokhroo et al. J Invasive Cardiol. 2016;28(1):1-8.
Ulnar artery interventions
non-inferior to radial approach (AJULAR)

45. Unprotected left main stenting
of patient with ACS
D. R.
Male
56 y.o.
Case 1.

46. RUA

48. RUA with 7.5F sheathless catheter

49. Left coronary artery

50. 7.5F Sheathless GC

51. DES 4.0/18

52. NC balloon postdilatation 4.5/12

53. Final result

54. Bilateral wrist access for
PCI of RCA CTO
- Retrograde approach-
Male
I. Z.
65 y.o.
Case 2.

55. Slika so bilateralen TRA so 6F

56. Left coronary artery: PBU 7.5F

57. Retrograde approach

58. Final result

59. Right UA CAS of RICA
G.I.
Male
73 y.o
Case 3.
Case 3.

60. RUА & RAO

61. 5F Shuttle sheath

62. RICA 99%

63. Final result- Roadsaver 7.0/30mm

64. Bilateral TRA & TUA for
PCI of prox. Cx CTO &
prox. RCA CTO
Male
D. B.
61 y.o.
Case 4.

65. RUA 7F and LRA 6F: PCI for CTO

66. Prox RCA CTO

67. Prox LCx CTO & LAD collaterals to RCA

68. Left coronary artery

69. Prox LCx: DES 2.75/28

70. Result

71. Bilateral Injections

72. RCA: Final result

73. Final result

74. Case 5.
Pt ND
RA angiography performed through cannula

75. One of 8 STEMI patients in the last 5
years that required change to TFA

76. Crossover to TFA

77. Ulnar access with ipsilateral RA Occlusion
Case 7.

78. • Pt M. D.
• UA Occlusion after previous multiple TRA and
TUA PCI
Case 8.

79. UA Occlusion

80. UA Occlusion after previous TUA
intervention

81. ACSy PCI in pt with RAO
Male
D. M.
37 y.o.
Case 9.

82. Previous history of mechanical injury to
his right hand 20 y. ago

83. Extensive collaterals from interosseus artery

84. Wire and catheter passing

85. Lesion on mid RCA

86. Stenting and final result

87. Hemostasis

89. Patent hemostasis

90. MISTAKE:
 Perform TRA only when FA is not possible !
 Do most of complex PCI’s through TFA
 Low treashold for FA crossover !
Wrist access

91. Conclusion
 UA is a safe and feasible alternative (second line)
wrist access.
 With careful technique and experienced operators,
the procedure can be performed with a high success rate
and low incidence of vascular complications.
 Further large-scale randomized studies are needed
to reconfirm the role of UA for CV procedures.

92.  Extensive complex arterial circulation
available in the upper extremity;
 Emerging data on ulnar access,
Final thought

93.  Extensive complex arterial circulation
available in the upper extremity;
 Emerging data on ulnar access,
Post-femoral era
for coronary angiography and intervention !
Final thought